Making Insulin Affordable for All Children Act
- Sponsor
- Rep. Landsman, Greg [D-OH-1]
- Committees
- Education and Workforce Committee (primary)
- Last action
- Apr 3, 2025
Bottom line
The bill aims to significantly reduce insulin costs for young people on private health plans by eliminating deductibles and capping monthly out-of-pocket expenses for essential insulin products.
What it actually does
This bill mandates that private health plans, including group and individual coverage, provide coverage for selected insulin products for individuals 26 years of age or younger without applying any deductible. It also caps the monthly out-of-pocket cost for a 30-day supply of these products at the lesser of $35 or 25% of the negotiated price, with these payments counting towards annual deductibles and out-of-pocket maximums.
Proponents argue
Supporters argue that this bill is a crucial step to ensure life-saving insulin is affordable and accessible for young people with diabetes, preventing financial hardship, medical debt, and potentially life-threatening rationing of medication. They emphasize that no one should have to choose between essential medicine and other necessities.
Opponents contend
Critics might contend that while the bill addresses a real affordability concern, mandating specific cost-sharing limits on private plans could lead to increased premiums for all plan participants or shift costs to other areas of healthcare, potentially distorting market incentives without addressing the underlying high list prices of insulin.
The bill is relatively short and clearly structured, making it accessible for an informed reader to understand its core provisions quickly.
Section 2(a), amending Part D of title XXVII of the Public Health Service Act (42 U.S.C. 300gg-111 et seq.)
Insulin Cost-Sharing Cap for Individuals 26 and Under
For plan years beginning on or after January 1, 2026, private health plans must cover 'selected insulin products' for enrollees aged 26 or younger. For these products, plans cannot apply any deductible and must cap cost-sharing at the lesser of $35 per 30-day supply or 25% of the negotiated price, after all price concessions. This aims to make insulin more affordable for young adults.
Supporters argue
This provision directly tackles the financial burden of insulin, ensuring that young people with diabetes can afford their life-saving medication without facing prohibitive deductibles or high monthly costs, thereby improving health outcomes and reducing medical debt.
Critics contend
Critics may argue that while well-intentioned, this mandate could lead to increased premiums for all plan participants as insurers seek to offset the absorbed costs, potentially shifting the financial burden to a broader group of consumers.
Tradeoffs
The provision balances the critical need for insulin affordability for a vulnerable population against the potential for increased costs for health plans and, indirectly, for other enrollees through higher premiums.
Section 2(b), amending Part D of title XXVII of the Public Health Service Act (42 U.S.C. 300gg-111 et seq.)
Definition of Selected Insulin Products
The bill defines 'selected insulin products' as at least one of each dosage form (e.g., vial, pump, inhaler) of each different type of insulin (e.g., rapid-acting, long-acting), as chosen by the group health plan or health insurance issuer. This ensures a range of insulin options are covered under the cost-sharing caps.
Section 2(d), amending Part D of title XXVII of the Public Health Service Act (42 U.S.C. 300gg-111 et seq.)
Application of Insulin Cost-Sharing to Out-of-Pocket Limits
Any cost-sharing payments made by individuals for selected insulin products under the new caps must be counted towards their annual deductible and out-of-pocket maximums under their health plan. This ensures that these payments contribute to overall financial protection.
Section 2(b), amending Section 1302(d)(2) of the Patient Protection and Affordable Care Act (42 U.S.C. 18022(d)(2))
Actuarial Value Calculation Exemption
This provision specifies that the exemption of selected insulin products from deductibles, as mandated by the bill, will not be considered when calculating the actuarial value of a qualified health plan. This technical adjustment helps ensure that plans can comply with the insulin mandate without negatively impacting their ability to meet existing Affordable Care Act actuarial value requirements.
Section 2(c), amending Section 1302(e) of the Patient Protection and Affordable Care Act (42 U.S.C. 18022(e))
Insulin Coverage in Catastrophic Health Plans
Catastrophic health plans are required to provide coverage for selected insulin products for individuals 26 years or younger, adhering to the new cost-sharing rules, even before the enrollee has met their high annual deductible. This ensures immediate access to affordable insulin for those on high-deductible plans.
The bill replicates the core cost-sharing provisions for insulin (no deductible, $35/25% cap, definitions, rule of construction, counting towards OOP max) by adding new sections to the Employee Retirement Income Security Act of 1974 (ERISA) and the Internal Revenue Code of 1986.
Sections 2(d) and 2(e)
Why it matters:This is standard legislative practice to ensure the mandate applies comprehensively across all types of private health plans, including fully-insured plans (governed by PHS Act), self-funded employer plans (governed by ERISA), and plans relevant to the tax code. It prevents loopholes based on plan type.
Case for: Ensures that the insulin cost-sharing caps are universally applied across the entire private health insurance market, regardless of how a plan is structured or regulated, thereby maximizing the policy's reach and effectiveness.
Case against: No specific opposition is typically raised against the mechanism of applying the law across different regulatory frameworks, though the underlying policy itself may face opposition.
Estimated impact: Ensures the policy covers millions of individuals under various plan types, significantly broadening its impact beyond just state-regulated plans.
This section authorizes the Secretary of Health and Human Services, the Secretary of Labor, and the Secretary of the Treasury to implement the provisions of the bill, including its amendments, through sub-regulatory guidance, program instruction, or otherwise.
Section 2(f)
Why it matters:This is a common legislative practice to provide administrative agencies with flexibility to issue detailed rules and clarifications necessary for practical implementation, without requiring further acts of Congress. However, it can also be seen as delegating significant policy-making authority outside the direct legislative process.
Case for: Allows for efficient and flexible implementation, enabling agencies to adapt to unforeseen issues, provide necessary clarifications, and respond to stakeholder feedback without requiring new legislation, which is crucial for complex health policy.
Case against: Critics of broad agency discretion might argue that it allows for significant policy details to be determined outside of the legislative process, potentially reducing transparency and congressional oversight over the final implementation of the law.
Estimated impact: This provision significantly impacts how smoothly and effectively the law is put into practice, influencing the specifics of compliance for health plans and the ultimate experience for consumers.